Coding inaccuracies in documentation of surgical procedures misrepresent the productivity of departments, with harmful fiscal consequences and detract from effective clinical governance. We aimed to assess the extent of this within our centres. We retrospectively analysed the operative records of 34 patients from two centres over a period of a month, undergoing varying arthroscopic knee operations. We found that 50% of cases had incorrect coding for procedures performed. On review of the clinical coding, the loss of payment summed up to £29,325. The flawed coding practices stemmed from the heterogeneity and convolution in documentation of procedures. Our intervention was the development of a multi-faceted arthroscopic operation note proforma, centred on concise documentation for appropriate codes to be gleaned. We re-audited our new proforma, retrospectively collating data on 37 patients over a period of five months undergoing arthroscopic knee procedures. We found only 5% of cases were coded incorrectly, summing to a loss in tariff payment of £2654. In conclusion, poor quality of documentation and written communication between surgical and coding departments can have drastic ramifications for funding. An active refinement of this process can ultimately help to provide more resources for improved patient care.
Keywords: arthroscopic surgery; arthroscopy; clinical coding; medical records; orthopaedics.
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